Systems and methods for treating acute and chronic heart failure

ABSTRACT

Systems and methods and devices are provided for arresting or reversing the effects of myocardial remodeling and degeneration after cardiac injury, without the potential drawbacks associated with previously existing systems and methods, by at least partially occluding flow through the superior vena cava over multiple cardiac cycles, and more preferably, by adjusting the interval or degree of occlusion responsive to a sensed level of patient activity. In some embodiments, a controller is provided that actuates a drive mechanism responsive to a sensed level of patient activity to provide at least partial occlusion of the patient&#39;s superior vena cava, while a data transfer circuit of the controller provides bi-directional transfer of physiologic data to the patient&#39;s smartphone or tablet to permit display and review of such data.

I. FIELD OF THE INVENTION

The disclosure relates to methods and systems for improving cardiacfunction in patients suffering from heart failure including patientswith reduced ejection fraction.

II. BACKGROUND OF THE INVENTION

Heart failure is a major cause of global mortality. Heart failure oftenresults in multiple long-term hospital admissions, especially in thelater phases of the disease. Absent heart transplantation, the long termprognosis for such patients is bleak, and pharmaceutical approaches arepalliative only. Consequently, there are few effective treatments toslow or reverse the progression of this disease.

Heart failure can result from any of multiple initiating events. Heartfailure may occur as a consequence of ischemic heart disease,hypertension, valvular heart disease, infection, inheritedcardiomyopathy, pulmonary hypertension, or under conditions of metabolicstress including pregnancy. Heart failure also may occur without a clearcause—also known as idiopathic cardiomyopathy. The term heart failureencompasses left ventricular, right ventricular, or biventricularfailure.

While the heart can often initially respond successfully to theincreased workload that results from high blood pressure or loss ofcontractile tissue, over time this stress induces compensatorycardiomyocyte hypertrophy and remodeling of the ventricular wall. Inparticular, over the next several months after the initial cardiacinjury, the damaged portion of the heart typically will begin to remodelas the heart struggles to continue to pump blood with reduced musclemass or less contractility. This in turn often leads to overworking ofthe myocardium, such that the cardiac muscle in the compromised regionbecomes progressively thinner, enlarged and further overloaded.Simultaneously, the ejection fraction of the damaged ventricle drops,leading to lower cardiac output and higher average pressures and volumesin the chamber throughout the cardiac cycle, the hallmarks of heartfailure. Not surprisingly, once a patient's heart enters thisprogressively self-perpetuating downward spiral, the patient's qualityof life is severely affected and the risk of morbidity skyrockets.Depending upon a number of factors, including the patient's priorphysical condition, age, sex and lifestyle, the patient may experienceone or several hospital admissions, at considerable cost to the patientand social healthcare systems, until the patient dies either of cardiacarrest or any of a number of co-morbidities including stroke, kidneyfailure, liver failure, or pulmonary hypertension.

Currently, there are no device-based solutions that specifically targeta reduction in preload to limit the progression of heart failure.Pharmaceutical approaches are available as palliatives to reduce thesymptoms of heart failure, but there exists no pharmaceutical path toarresting or reversing heart failure. Moreover, the existingpharmaceutical approaches are systemic in nature and do not address thelocalized effects of remodeling on the cardiac structure. It thereforewould be desirable to provide systems and methods for treating heartfailure that can arrest, and more preferably, reverse cardiac remodelingthat result in the cascade of effects associated with this disease.

Applicants note that the prior art includes several attempts to addressheart failure. Prior to applicants' invention as described herein, thereare no effective commercial devices available to treat this disease.Described below are several known examples of previously known systemsand methods for treating various aspects of heart failure, but noneappear either intended to, or capable of, reducing left ventricular enddiastolic volume (“LVEDV”), left ventricular end diastolic pressure(“LVEDP”), right ventricular end diastolic volume (“R down VEDV”), orright ventricular end diastolic pressure (“RVEDP”) without causingpossibly severe side-effects.

For example, U.S. Pat. No. 4,546,759 to Solar describes a triple ballooncatheter designed for placement such that a distal balloonintermittently occludes the superior vena cava, a proximal balloonintermittently occludes the inferior vena cava, and an intermediateballoon expands synchronously with occurrence of systole of the rightventricle, thereby enhancing ejection of blood from the right ventricle.The patent describes that the system is inflated and deflated insynchrony with the normal heart rhythm, and is designed to reduce theload on the right ventricle to permit healing of injury or defect of theright ventricle. It does not describe or suggest that the proposedregulation of flow into and out of the right ventricle will have aneffect on either LVEDV or LVEDP, nor that it could be used to arrest orreverse acute/chronic heart failure.

U.S. Patent Publication No. US 2006/0064059 to Gelfand describes asystem and method intended to reduce cardiac infarct size and/ormyocardial remodeling after an acute myocardial infarction by reducingthe stress in the cardiac walls. The system described in the patentincludes a catheter having a proximal portion with an occlusion balloonconfigured for placement in the inferior vena cava and a distal portionconfigured for placement through the tricuspid and pulmonary valves intothe pulmonary artery. The patent application describes that by partiallyoccluding the inferior vena cava, the system regulates the amount ofblood entering the ventricles, and consequently, reduces the load on theventricles, permitting faster healing and reducing the expansion of themyocardial infarct. The system described in Gelfand includes sensorsmounted on the catheter that are read by a controller to adjustregulation of the blood flow entering the heart, and other measuredparameters, to within predetermined limits. The patent application doesnot describe or suggest that the system could be used to treat, arrestor reverse congestive heart failure once the heart has already undergonethe extensive remodeling typically observed during patient re-admissionsto address the symptoms of congestive heart failure.

U.S. Patent Publication No. US 2010/0331876 to Cedeno describes a systemand method intended to treat congestive heart failure, similar in designto described in Gelfand, by regulating the return of venous bloodthrough the inferior vena cava. The system described in Cedeno describesthat a fixed volume balloon disposed in the inferior vena cava willlimit blood flow in the IVC. The degree of occlusion varies as thevessel expands and contracts during inspiration and expiration, tonormalize venous blood return. The patent application further describesthat the symptoms of heart failure improve within three months of use ofthe claimed system. Although the system and methods described in Cedenoappear promising, there are a number of potential drawbacks to such asystem that applicants' have discovered during their own research.Applicants have observed during their own research that fully occludingthe inferior vena cava not only reduces left ventricular volume, butundesirably also left ventricular pressure, leading to reduced systemicblood pressure and cardiac output. Moreover, full inferior vena cavaocclusion may increase venous congestion within the renal, hepatic, andmesenteric veins; venous congestion is a major cause of renal failure incongestive heart failure patients.

There are several major limitations to approaches that involve partialor full occlusion of the inferior vena cava to modulate cardiac fillingpressures and improve cardiac function. First, the IVC has to be reachedvia the femoral vein or via the internal jugular vein. If approached viathe femoral vein, then the patient will be required to remain supine andwill be unable to ambulate. If approached via the jugular or subclavianveins, the apparatus would have to traverse the superior vena cava andright atrium, thereby requiring cardiac penetration, which predisposesto potential risk involving right atrial injury, induction ofarrhythmias including supraventricular tachycardia or bradycardia due toheart block. Second, the IVC approach described by Cedeno and colleaguesdepends on several highly variable indices (especially in the setting ofcongestive heart failure): 1) IVC diameter, which is often dilated inpatients with heart failure; b) Intermittent (full or partial) IVCocclusion may cause harm by increasing renal vein pressure, whichreduces glomerular filtration rates and worsens kidney dysfunction; c)Dependence on the patient's ability to breathe, which is often severelyimpaired in HF. A classic breathing pattern in HF is known as CheynesStokes respiration, which is defined by intermittent periods of apneawhere the IVC may collapse and the balloon will cause complete occlusionresulting in lower systemic blood pressure and higher renal veinpressure; d) If prolonged cardiac unloading is required to see aclinical improvement or beneficial changes in cardiac structure orfunction, then IVC occlusion will not be effective since sustained IVCocclusion will compromise blood pressure and kidney function. Third, theapproach defined by Cedeno will require balloon customization dependingon IVC size, which may be highly variable. Fourth, many patients withheart failure have IVC filters due to an increased propensity for deepvenous thrombosis, which would preclude broad application of IVCtherapy.

In view of the foregoing drawbacks of the previously known systems andmethods for regulating venous return to address heart failure, it wouldbe desirable to provide systems and methods for treating acute andchronic heart failure that reduce the risk of exacerbatingco-morbidities associated with the disease.

It further would be desirable to provide systems and methods fortreating acute and chronic heart failure that arrest or reverse cardiacremodeling, and are practical for chronic and/or ambulatory use.

It still further would be desirable to provide systems and methods fortreating heart failure that permit patients suffering from this diseaseto have improved quality of life, reducing the need for hospitaladmissions and the associated burden on societal healthcare networks.

III. SUMMARY OF THE INVENTION

In view of the drawbacks of the previously known systems and methods fortreating heart failure, it would be desirable to provide systems andmethods for treating acute and/or chronic heart failure that can arrest,and more preferably, reverse cardiac remodeling that result in thecascade of effects associated with this disease.

It further would be desirable to provide systems and methods forarresting or reversing cardiac remodeling in patients suffering fromheart failure that are practical for ambulatory and/or chronic use.

It still further would be desirable to provide systems and methods fortreating heart failure that reduce the risk of exacerbatingco-morbidities associated with the disease, such as venous congestionresulting in renal and hepatic complications.

It also would be desirable to provide systems and methods for treatingheart failure that permit patients suffering from this disease to haveimproved quality of life, which reducing the need for hospitalre-admissions and the associated burden on societal healthcare networks.

These and other advantages are provided by the present disclosure, whichprovides systems and methods for regulating venous blood return throughthe superior vena cava (“SVC”), over intervals spanning several cardiaccycles, to reduce ventricular overload. In accordance with theprinciples of the present disclosure, venous regulation via the SVC canbe used to reduce LVEDP, LVEDV, RVEDP, and/or RVEDV, to arrest orreverse ventricular myocardial remodeling. Counter-intuitively,applicants have observed in preliminary animal testing that intermittentpartial occlusion of the SVC does not lead to stagnation of cerebralflow or observable adverse side effects. More importantly, applicants'preliminary animal testing reveals that occlusion of the SVC results insignificant reduction in both RVEDP and LVEDP, while improving totalcardiac output and without a significant impact on left ventricularsystolic pressure (“LVSP”). Accordingly, unlike the approach discussedin the foregoing published Cedeno patent application, the presentdisclosure provides a beneficial reduction in LVEDP, LVEDV, RVEDP,and/or RVEDV, with negligible impact on LVSP, but improved stroke volume(cardiac output), and reduced risk for venous congestion resulting inincreased co-morbidities. The systems and methods described hereinprovide acute improvement in cardiac filling pressures and function tobenefit patients at risk for acutely decompensated heart failure.

There are several major advantages to targeting SVC flow (instead of IVCflow). First, device placement in the SVC avoids use of the femoralveins and avoids cardiac penetration. This allows for development of afully implantable, ambulatory system for acute or chronic therapy.Second, SVC occlusion can be intermittent or prolonged depending on themagnitude of unloading required. Unlike IVC occlusion, prolonged SVCocclusion maintains systemic blood pressure and improves cardiac output.This allows for sustained unloading of both the right and leftventricle, which allows for both acute hemodynamic benefit and thepotential for long term beneficial effects on cardiac structure orfunction. Third, unlike IVC occlusion, SVC occlusion does not depend onpatient respiration. Fourth, by developing an internal regulator of SVCocclusion driven by mean right atrial pressure, the SVC device can beprogrammed and personalized for each patient's conditions. Fifth, byplacing the device in the SVC, the device can be used in patients withexisting IVC filters.

In accordance with another aspect of the present disclosure, partialintermittent occlusion of the SVC over multiple cardiac cycles isexpected to permit the myocardium to heal, such that the reduced wallstress in the heart muscle arrests or reverses the remodeling that issymptomatic of the progression of heart failure. Without wishing to bebound by theory, applicants believe that intermittent occlusion of theSVC permits the heart, when implemented over a period of hours, days,weeks, or months, to transition from a Starling curve indicative ofheart failure with reduced ejection fraction towards a Starling curvehaving LVEDP and LVEDP more indicative of normal cardiac function.Consequently, applicants preliminary animal testing suggests that use ofthe inventive system over a period of hours, days, weeks, or months,e.g., 3-6 months, may not only arrest the downward spiral typical of thedisease, but also may enable the heart to recover function sufficientlyfor the patient to terminate use of either the system of the presentdisclosure, pharmaceutical treatments, or both.

In accordance with another aspect of the disclosure, a system isprovided that comprises a catheter having an flow limiting elementconfigured for placement in the SVC, and a controller for controllingactuation of the flow limiting element. The controller is preferablyprogrammed to receive an input indicative of fluctuations in thepatient's hemodynamic state resulting from the patient's ambulatoryactivity, and to regulate actuation of the flow limiting elementresponsive to that input. The controller may be programmed at the timeof implantation of the catheter to retain full or partial occlusion ofthe SVC over a predetermined number of heart cycles or predeterminedtime interval based on the patient's resting heart rate, and this presetnumber of cycles or time interval may be continually adjusted by thecontroller responsive to the patient's heart rate input. The controllermay further receive signals from sensors and/or electrodes indicative ofsensed parameters reflecting the hemodynamic state, e.g., blood flowrate, blood volume, pressure including cardiac filling pressure, and thecontroller may continually adjust the preset number of cycles or timeinterval responsive to the sensed parameter(s).

In one preferred embodiment, the catheter is configured to be implantedvia the patient's left subclavian vein, so that the flow limitingelement is disposed in the SVC just proximal of the right atrium. Aproximal end of the catheter may be coated or impregnated with anantibacterial agent to reduce infection at the site where the catheterpasses transcutaneously. The controller preferably is battery-powered,and includes a quick-connect coupling that permits the actuationmechanism of the controller to operatively couple to the flow limitingelement. In a preferred embodiment, the controller is sufficiently smallthat it may be worn by the patient in a harness around the shoulder. Incontrast to previously-known systems, which tether the patient to a bedor acute-care setting, the system of the present disclosure isconfigured so that the patient is ambulatory and can go about most dailyactivities, thereby enhancing the patient's quality-of-life andimproving patient compliance with the course of treatment using theinventive system. In one embodiment, the controller is configured forimplantation at a suitable location within the patient, e.g.,subcutaneously under the clavicle. In such an embodiment, theimplantable controller is configured for bidirectional communicationwith an external controller, e.g., mobile device or system-specificdevice. The external controller may be configured to charge the batteryof the implantable controller, e.g., via respective inductive coils ineach controller, and may receive data indicative of the sensedparameters including heart rate, blood flow rate, blood volume, pressureincluding cardiac filling pressure.

In a preferred embodiment, the flow limiting element comprises anon-compliant or semi-compliant balloon affixed to a distal region ofthe catheter, such that the controller actuates the balloon byperiodically inflating and deflating the balloon to selectively fully orpartially occlude the SVC. In alternative embodiments, the flow limitingelement may comprise a membrane covered umbrella, basket or othermechanical arrangement capable of being rapidly transitioned betweendeployed and contracted positions, e.g., by a driveline connected to thecontroller. In still further embodiments, the flow limiting element maytake the form of a butterfly valve or ball valve, provided the flowlimiting element does not create stagnant flow zones in the SVC when inthe contracted or open position.

The inventive system may include a sensor disposed on the catheter forplacement within the venous vasculature to measure the patient's heartrate or blood pressure. The sensor preferably generates an output signalthat is used as an input to the controller to adjust the degree ortiming of the occlusion created by the flow limiting element. In anotherembodiment, the controller may be configured to couple to a third-partyheart rate sensor, such as those typically used by sporting enthusiasts,e.g., the Fitbit, via available wireless standards, such as Bluetooth,via the patient's smartphone. In this embodiment, the cost, size andcomplexity of the controller may be reduced by integrating it withcommercially available third-party components.

In accordance with another aspect of the disclosure, a method forcontrolling blood flow in a patient comprises inserting and guiding tothe vena cava of a patient a venous occlusion device, coupling theocclusion device to a controller worn externally by, or implanted in,the patient; and activating the venous occlusion device intermittently,for intervals spanning multiple cardiac cycles, so that over a period ofseveral minutes, hours, days, weeks, or months, remodeling of themyocardium is arrested or reversed.

IV. BRIEF DESCRIPTION OF THE DRAWINGS

The characteristics and advantages of the present disclosure will becomeapparent from the detailed description of the embodiment of thedisclosure presented below in conjunction with the attached drawings, inwhich:

FIG. 1A is a frontal, partially broken-away view of the major arteriesand veins of the heart.

FIG. 1B illustrates the vena cava including major veins associated withthe vena cava.

FIG. 2 is a graph illustrating the Frank-Starling curve for normal andafflicted cardiac conditions.

FIG. 3 is a graph of exemplary pressure-volume loop curves of leftventricular pressure versus left ventricular volume throughout a cardiaccycle for a patient having normal cardiac function and a patientsuffering from congestive heart failure.

FIG. 4 is a schematic drawing of a system constructed in accordance withthe principles of the present disclosure.

FIGS. 5A-5B are schematic drawings of the catheter of FIG. 4 wherein theflow limiting element comprises a cylindrical balloon with modifiedanchoring members shown in its expanded and contracted states,respectively.

FIG. 6 is a schematic drawing of the catheter of FIG. 4 wherein the flowlimiting element comprises a mechanically actuated membrane coveredbasket.

FIG. 7 is a cross-sectional view of the catheter of FIG. 4.

FIGS. 8A and 8B are schematic drawings of an flow limiting elementcomprising a round ball-shaped balloon shown in its expanded andcontracted states, respectively.

FIGS. 9A and 9B are schematic drawings of an flow limiting elementcomprising a spring-loaded plug shown in its expanded and contractedstates, respectively.

FIGS. 10A and 10B are schematic drawings of an flow limiting elementcomprising an alternative embodiment of a spring-loaded plug shown inits expanded and contracted states, respectively.

FIG. 11 is a graph showing the changes in left ventricle systolic anddiastolic pressures, LV volume, and aortic pressure as a function oftime following occlusion of either the inferior vena cava (IVC) or thesuperior vena cava (SVC) in a swine subjected to heart failure inaccordance with the principles of the present disclosure.

FIG. 12 are hemodynamic tracings showing the changes in pulmonary arteryand renal vein pressures as a function of time following occlusion ofeither the inferior vena cava (IVC) or the superior vena cava (SVC) in aswine subjected to heart failure in accordance with the principles ofthe present disclosure.

FIGS. 13-14 are graphs showing the changes in pressure as a function ofleft and right ventricular volume, respectively, during occlusion of thesuperior vena cava (SVC) and release in a swine subjected to heartfailure in accordance with the principles of the present disclosure.

FIGS. 15-22 show test results for swine subjects subjected to heartfailure.

V. DETAILED DESCRIPTION OF THE INVENTION

Referring to FIGS. 1A and 1B, the human anatomy in which the presentdisclosure is designed for placement and operation is described ascontext for the system and methods of the present disclosure.

More particularly, referring to FIG. 1A, deoxygenated blood returns toheart 10 through vena cava 11, which comprises superior vena cava 12 andinferior vena cava 13 coupled to right atrium 14 of the heart. Bloodmoves from right atrium 14 through tricuspid valve 15 to right ventricle16, where it is pumped via pulmonary artery 17 to the lungs. Oxygenatedreturns from the lungs to left atrium 18 via the pulmonary vein. Theoxygenated blood then enters left ventricle 19, which pumps the bloodthrough aorta 20 to the rest of the body.

As shown in FIG. 1B, superior vena cava 12 is positioned at the top ofvena cava 11, while inferior vena cava 13 is located at the bottom ofthe vena cava. FIG. 1B also shows some of the major veins connecting tothe vena cava, including right hepatic vein 21, middle hepatic vein 22,left hepatic vein 23 and suprarenal vein 24. As noted above, occlusionof the inferior vena cava 13 may pose risks of venous congestion, and inparticular, potential blockage or enlargement of the hepatic veinsand/or suprarenal vein that may worsen, rather than improve, thepatient's cardiovascular condition and overall health.

In accordance with one aspect of the present disclosure, applicants havedetermined that selective intermittent occlusion of the superior venacava (“SVC”) poses fewer potential adverse risks that occlusion of theinferior vena cava (“IVC”). Moreover, applicants' preliminary animaltesting reveals that controlling the return of venous blood to the rightventricle by partially or fully occluding the SVC beneficially lowersRVEDP, RVEDV, LVEDP and LVEDV without adversely reducing leftventricular systolic pressure (LVSP), as was observed when occluding theIVC in applicants' animal model.

Applicants expect that selective intermittent occlusion of the SVCposition will reduce the risk of worsening congestion of the kidneys,which is a major cause of ‘cardio-renal’ syndrome, as compared to IVCocclusion. Cardio-renal syndrome is impaired renal function due tovolume overload and neurohormonal activation in patients with heartfailure. In addition, implantation in the SVC permits asupra-diaphragmatic device implant that could not be used in the IVCwithout cardiac penetration and crossing the right atrium. Further,implantation of the occluder in the SVC avoids the need for groin accessas required by IVC implantation, which would limit mobility making anambulatory device impractical for short term or long term use. Inaddition, minor changes in IVC occlusion (time or degree) may cause moredramatic shifts in preload reduction and hence total cardiacoutput/systemic blood pressure whereas the systems and methods of thepresent disclosure as expected to permit finely tuned decrease in venousreturn (preload reduction),

While not wishing to be bound by theory, it is applicants' expectationthat their proposed system and method for regulating venous bloodreturn, if implemented over a period of hours, days, weeks, or months,will beneficially permit a patients' heart to arrest or recover fromremodeling of the myocardium. Applicants' preliminary animal testingindicates that the system enables the myocardium to transition frompressure-stroke volume curve indicative of heart failure towards apressure-stroke volume curve more closely resembling that of a healthyheart.

In general, the system and methods of the present disclosure may be usedto treat any disease to improve cardiac function by arresting orreversing myocardial remodeling, and particularly those conditions inwhich a patient suffers from heart failure. Such conditions include butare not limited to, e.g., systolic heart failure, diastolic(non-systolic) heart failure, decompensated heart failure patients in(ADHF), chronic heart failure, acute heart failure. The system andmethods of the present disclosure also may be used as a prophylactic tomitigate the aftermath of acute right or left ventricle myocardialinfarction, pulmonary hypertension, RV failure, post-cardiotomy shock,or post-orthotopic heart transplantation (OHTx) rejection.

The relationship between left ventricular pressure or left ventricularvolume and stroke volume is often referred to as the Frank-Starlingrelationship, or “Starling curve.” That relationship states that cardiacstroke volume is dependent on preload, contractility, and afterload.Preload refers to the volume of blood returning to the heart;contractility is defined as the inherent ability of heart muscle tocontract; and afterload is determined by vascular resistance andimpedance. In heart failure due to diastolic or systolic dysfunction,reduced stroke volume leads to increased volume and pressure increase inthe left ventricle, which can result in pulmonary edema. Increasedventricular volume and pressure also results in increased workload andincreased myocardial oxygen consumption. Such over-exertion of the heartresults in worsening cardiac function as the heart becomes increasinglydeprived of oxygen due to supply and demand mismatch. Furthermore, asvolume and pressure build inside the heart, contractile function worsensdue to stretching of cardiac muscle. This condition is termed‘congestive heart failure’.

Referring to FIG. 2, a series of Starling curves are illustrated, inwhich topmost curve (curve 1) depicts functioning of a normal heart. Asshown in the curve, stroke volume increases with increasing LVEDP orLVEDV, and begins to flatten out, i.e., the slope of the curvedecreases, only at very high pressures or volumes. A patient who hasjust experienced an acute myocardial infarction (“AMI”), as indicated bythe middle curve (curve 2), will exhibit reduced stroke volume at everyvalue of LVEDV or LVEDP. However, because the heart has just begun toexperience the overload caused by the localized effect of the infarct,myocardial contractility of the entire ventricle is still relativelygood, and stroke volume is still relatively high at low LVEDP or LVEDV.By contrast, a patient who has suffered from cardiac injury in the pastmay experience progressive deterioration of cardiac function as themyocardium remodels over time to compensate for the increased workloadand reduced oxygen availability, as depicted by the lowermost curve(curve 3) in FIG. 2. As noted above, this can lead to progressivelylower stroke volume as the ventricle expands due to generally highervolume and pressure during every phase of the cardiac cycle. As will beobserved from comparison of curves 1 and 3, the stroke volume continuesto decline as the LVEDP or LVEDV climb, until eventually the heart givesout or the patient dies of circulatory-related illness.

FIG. 3 illustratively shows pressure-volume loops for a normal heart,labeled “normal”, corresponding to curve 1 in FIG. 2, and a heartsuffering from congestive heart failure, labeled “CHF” (curve 3 in FIG.2). For each loop, the ventricular volume and pressure at the end ofdiastole correspond to the lower-most, right-most corner of the loop(point A), while the upper-most, left-most corner of each loopcorresponds to the beginning systole (point B). The stroke volume foreach pressure-volume loop corresponds to the area enclosed within theloop. Accordingly, the most beneficial venous regulation regime is onethat reduces the volume and pressure at point A while not also causingnegligible reduction in point B, thereby maximizing the stroke volume.

In accordance with one aspect of the present disclosure, the system andmethods of the present disclosure are designed, over the course ofhours, days, weeks, or months, to shift or transition the Starling curveof the patient's heart leftwards on the diagram of FIG. 2 (or to movethe pressure-volume loop in FIG. 3 leftwards and downwards). This may beaccomplished by intermittently fully or partially occluding the SVC toreduce the volume and hence pressure of blood entering the rightventricle, and which must then be pumped by the left ventricle.Applicants' preliminary animal testing indicates that such intermittentocclusion, maintained over several cardiac cycles, reduces the workloadand wall stress in the myocardium throughout the cardiac cycle, reducesmyocardial oxygen consumption, and improves contractile function. Seealso, FIGS. 13 and 14 discussed below.

Referring now to FIG. 4, exemplary system 30 of the present disclosureis described. System 30 includes catheter 31 having flow limitingelement 32 coupled to controller 33 programmed to intermittently actuateflow limiting element 32. As discussed below, system optionally may beconfigured to transfer information bi-directionally with conventionalcomputing device 45 such as a smartphone, laptop, smartwatch, or tablet,illustratively an Apple iPhone 5 or iPad, available from Apple Inc.,Cupertino, Calif., on which a special-purpose application has beeninstalled to communicate and/or control controller 33.

Preferably, catheter 31 comprises a flexible tube having distal portion34 configured for placement in the SVC. Distal portion 34 includes flowlimiting element 32 that, in use, is disposed in superior vena cava 12(see FIG. 2) of a patient to selectively impede blood flow into rightatrium 14. In this embodiment, flow limiting element 32 illustrativelycomprises a balloon capable of transitioning between a contracted state,allowing transluminal placement and an expanded, deployed state. Flowlimiting element 32 preferably is sized and shaped so that it partiallyor fully occludes flow in the SVC in the expanded state. Catheter 31 iscoupled at proximal end 35 to controller 33, which houses drivemechanism 36 (e.g., motor, pump) for actuating flow limiting element 32,processor 37 programmed to control signals to drive mechanism 36, andoptional sensor 38 for monitoring a physiologic parameter of thepatient, such as heart rate or blood pressure.

Controller 33 may include source of inflation medium 48 (e.g., gas orfluid) and drive mechanism 36 may transfer the inflation medium betweenthe source and flow limiting element 32 responsive to commands fromprocessor 37. When flow limiting element 32 is inflated with inflationmedium, it partially or fully occludes venous blood flow through theSVC; when the inflation medium is withdrawn, flow limiting element 32deflates to remove the occlusion, thereby permitting flow to resume inthe SVC. Flow limiting element 32 may be a balloon that preferablycomprises a compliant or semi-compliant material, e.g., nylon, whichpermits the degree of expansion of the balloon to be adjusted toeffectuate the desired degree of partial or complete occlusion of theSVC. In addition, catheter 31, when partially external, provides afail-safe design, in that flow limiting element 32 only can be inflatedto provide occlusion when the proximal end of catheter 31 is coupled tocontroller 33. Such a quick-disconnect coupling 40 at proximal end 35permits the catheter to be rapidly disconnected from controller 33 forcleaning and/or emergency.

Controller 33 preferably also includes power supply 39 (e.g., battery)that provides the power needed to operate processor 37, drive mechanism36 and data transfer circuit sensor 38. Controller 33 preferably issized and of such a weight that it can be worn in a harness under thepatient's clothing, so that the system can be used while the patient isambulatory or such that controller 33 may be implanted within thepatient. As discussed herein below, processor 37 includes memory 41 forstoring computer software for operating the controller 33.

Controller 33 also may be configured for implantation at a suitablelocation within the patient, e.g., subcutaneously under the clavicle. Insuch an embodiment, the implantable controller is configured forbidirectional communication with an external controller, e.g., computingdevice 45 or system-specific device. The external controller may beconfigured to charge the battery of the implantable controller, e.g.,via respective inductive coils in or coupled to each controller, and mayreceive data indicative of the sensed parameters resulting from thepatient's ambulatory activity including heart rate, blood flow rate,blood volume, pressure including cardiac filling pressure.

In one embodiment, data transfer circuit 38 monitors an input from anexternal sensor, e.g., positioned on catheter 31, and provides thatsignal to processor 37. Processor 37 is programmed to receive the inputfrom data transfer circuit 38 and adjust the interval during which flowlimiting element 32 is maintained in the expanded state, or to adjustthe degree of occlusion caused by flow limiting element 32. Thus, forexample, catheter 31 may have optional sensor 42 positioned withindistal region 34 of the catheter to measure parameters, e.g., heartrate, blood flow rate, blood volume, pressure including cardiac fillingpressure and central venous pressure. The output of sensor 42 is relayedto data transfer circuit 38 of controller 33, which may pre-process theinput signal, e.g., decimate and digitize the output of sensor 42,before it is supplied to processor 37. The signal provided to processor37 allows for assessment of the effectiveness of the flow limitingelement, e.g., by showing reduced venous pressure during occlusion andduring patency, and may be used for patient or clinician to determinehow much occlusion is required to regulate venous blood return based onthe severity of congestion in the patient. Additionally, sensor 43 maybe included on catheter 31 proximal to flow limiting element 32, tomeasure parameters, e.g., heart rate, blood flow rate, blood volume,pressure including cardiac filling pressure and central venous pressure.Sensor 43 may be used to determine the extent of occlusion caused byelement 32, for example, by monitoring the pressure drop across the flowlimiting element.

As another example, catheter 31 may include electrodes 44 for sensingthe patient's heart rate. It is expected that it may be desirable toadjust the interval during which occlusion of the SVC is maintainedresponsive to the patient's ambulatory activities, which typically willbe reflected in the patient's hemodynamic state by a sensedphysiological parameter(s), e.g., heart rate, blood flow rate, bloodvolume, pressure including cardiac filling pressure and/or centralvenous pressure. Accordingly, electrodes 44 may provide a signal to datatransfer circuit 38, which in turn processes that signal for use by theprogrammed routines run by processor 37. For example, if the occlusionis maintained for a time programmed during initial system setup toreflect that the patient is resting, e.g., so that flow limiting elementis deployed for 5 seconds and then released for two seconds before beingre-expanded, it may be desirable to reduce that the occluded timeinterval to 4 seconds or more depending upon the level of physicalactivity of the patient, as detected by a change in heart rate, bloodflow rate, blood volume, pressure including cardiac filling pressureand/or central venous pressure above or below predetermined thresholds.Alternatively, processor 37 may be programmed to maintain partial orfull occlusion in the SVC for a preset number of cardiac cyclesdetermined at the time of initial implantation of the catheter. Sensorinputs provided to data transfer circuit 38, such as hemodynamic state,also may be used to adjust the duty cycle of the flow limiting elementresponsive to the patient's detected level of activity. In addition,processor 37 may be programmed to maintain partial or full occlusion inthe SVC for a preset number of cardiac cycles after adjustment to thepredetermined occlusion interval is made.

Data transfer circuit 38 also may be configured to providebi-directional transfer of data, for example, by including wirelesscircuitry to transfer data from controller 33 to an external unit fordisplay, review or adjustment. For example, data transfer circuit mayinclude Bluetooth circuitry that enables controller 33 to communicatewith patient's computing device 45. In this manner, controller may sendinformation regarding functioning of the system directly to computingdevice 45 for display of vital physiologic or system parameters using asuitably configured mobile application. In addition, the patient mayreview the data displayed on the screen of computing device 45 anddetermine whether he or she needs to seek medical assistance to addressa malfunction or to adjust the system parameters. Further, the mobileapplication resident on computing device 45 may be configured toautomatically initiate an alert to the clinician's monitoring servicevia the cellular telephone network.

Optionally, data transfer circuit 38 may be configured to synchronize toreceive data from other mobile applications on computing device 45, andthus reduce the cost and complexity of the inventive system. Forexample, a number of third party vendors, such as Fitbit, Inc., SanFrancisco, Calif., market monitors that measure physiologic parametersin real time, such as the Charge HR wristband monitor, that measuresphysical activity and heart rate. In accordance with one aspect of thedisclosure, data transfer circuit 38 can be programmed to receive aninput from such a third-party monitor via wireless communication withcomputing device 45, and that processor 37 may be programmed to controlactivation of drive mechanism 36 responsive to that input. In thisembodiment, the catheter need not include optional sensor 42, sensor 43or electrodes 44, thereby greatly simplifying the construction ofcatheter 31 and coupling 40.

Catheter 31 may include anchor member 46 configured to anchor flowlimiting element 32 within the SVC. Anchor member 46 may be contractablefor delivery in a contracted state and expandable upon release from adelivery device, e.g., a sheath. Anchor member 46 may be coupled tocatheter proximal or distal to flow limiting element 32 and/or may becoupled to flow limiting element 32.

Referring now to FIGS. 5A and 5B, an exemplary embodiment of catheter31′ is described, wherein catheter 31′ is constructed similarly tocatheter 31 of FIG. 4 except with a modified anchor. As shown in FIG. 5Awhen flow limiting element 32′ is in an expanded, fully occluding state,and shown in FIG. 5B, when flow limiting element 32′ is in a contractedstate, catheter 31′ may include radially expanding anchoring arms 49.Anchoring arms 49 are configured to radially expand, e.g., when exposedfrom a delivery sheath, to contact the inner wall of superior vena cava12 and anchor flow limiting element 32′ therein.

Referring now to FIG. 6, an alternative embodiment is described whereinthe occlusion may comprise a wire basket. Flow limiting element 50 maybe formed of a biocompatible material, such as nickel-titanium orstainless steel, and comprises plurality of axially or spirallyextending wires 51 that are biased to expand radially outward whencompressed. Flow limiting element 50 preferably includes a biocompatiblemembrane covering, so that it partially or fully occludes flow in theSVC in the expanded state. Wires 51 may be coupled at distal end 52 todistal end 53 of actuation wire 54, and affixed to ring 55 at theirproximal ends 56. Ring 55 is disposed to slide on actuation wire 54 sothat when actuation wire 54 is pulled in the proximal direction againstsheath 57 (see FIGS. 5A and 5B), wires 51 expand radially outward. Asshown in FIG. 5B, in response to a force applied to the proximal end ofactuation wire 54 by drive mechanism 36, actuation wire 54 is retractedproximally against sheath 57 of the catheter; transitioning flowlimiting element 50 to its expanded deployed state. Conversely, whendrive mechanism 36 is deactivated, spring force applied by wires 51pulls actuation wire 54 in the proximal direction, thereby enablingwires 51 to return to their uncompressed state, lying substantially flatagainst actuation wire 54. As noted above, flow limiting element 50 hasa “fail safe” design, so that the flow limiting element resumes thecollapsed, contracted state shown in FIG. 5A when catheter 31 isuncoupled from drive mechanism 36. In this embodiment, drive mechanism36 may be a motor, which may be a linear motor, rotary motor,solenoid-piston, or wire motor.

Flow limiting element 50 may be constructed so that it is biased to thecontracted position when catheter 31 is disconnected from controller 33,so that flow limiting element 50 can only be transitioned to theexpanded, deployed state when the catheter is coupled to controller 33and the processor has signaled drive mechanism 36 to expand the flowlimiting element.

Referring still to FIG. 6, flow limiting element 50 preferably includesa sheer biocompatible elastic membrane 58 disposed on wires 51, such asexpanded polytetrafluoroethylene (ePTFE), which occludes blood flowthrough the SVC when the flow limiting element is in the expandeddeployed state. A suitable ePTFE material can be obtained, for example,from W. L. Gore & Associates, Inc., Flagstaff, Ariz.

Referring now to FIG. 7, catheter 31 preferably includes at least threelumens 60, 61, 62. Lumen 60 may be used as an inflation lumen (FIGS.4-5B) and/or for carrying actuation wire 54 (FIG. 6) that extendsbetween flow limiting element 50 and the drive mechanism 36 ofcontroller 33. Lumen 61 permits optional sensors 42, 43 or electrodes tocommunicate with data transfer circuit 38, and optional lumen 62 fordelivering a pharmacological agent (e.g., a drug) to the heart.

In operation, catheter 31 with flow limiting element 32/50 is insertedinto the patient's subclavian vein and guided to the SVC of the patient,e.g., to a position proximal of the entrance to the right atrium (seeFIG. 1A). Techniques known in the art can be used to insert and fix flowlimiting element 32/50 at the desired venous location in the patient.Proper localization of the device may be confirmed using, for example,vascular ultrasound. Alternatively, flow limiting element 32/50 may beinserted through the jugular vein and guided to the SVC underfluoroscopic or ultrasound guidance.

Once catheter 31 and flow limiting element 32/50 are positioned at thedesired locations, controller 33 initiates a process in which theocclusion element is expanded and contracted such that blood flow in theSVC is intermittently occludes and resumed. The extent to which the flowlimiting element impedes blood flow can be regulated by adjusting thedegree to which the flow limiting element expands radially, and also fortime interval for the occlusion, e.g., over how many heart beats. Forexample, in some embodiments the flow limiting element may impede bloodflow in the SVC by anywhere from at least 50% up to 100%. Impedance ofblood flow may be confirmed using methods known in the art, e.g., bymeasuring reductions in pressure or visually using ultrasound.

In accordance with one aspect of the disclosure, controller 33 includessoftware stored in memory 41 that controls the timing and duration ofthe successive expansions and contractions of flow limiting element32/50. As described above, the programmed routines run by processor 37may use as an input the patient's cardiac cycle. For example, in someembodiments, the software may be configured to actuate flow limitingelement 50 to maintain partial or complete occlusion of the SVC overmultiple cardiac cycles, for example, four or more successive heartbeats in the subject. Controller 33 may accept as input via datatransfer circuit 38 an output of electrodes 44 representative of thepatient's electrocardiogram (ECG), or alternatively may receive such aninput wirelessly from a third-party heart rate application running onthe patient's smartphone, such that the software running on processor 37can adjust the interval and/or degree of the occlusion provided bysystem 30 responsive to the patient's heart rate. Thus, for example, ifthe patient is physically active, the timing or degree of occlusioncaused by the flow limiting element may be reduced to permit fasterreplenishment of oxygenated blood to the patient's upper extremities.Conversely, if the heart rate indicates that the patient is inactive,the degree of occlusion of the SVC may be increased to reduce theresting workload on the heart. Alternatively or in addition, system 30may accept an input via data transfer circuit 38 a value, measured byoptional sensors 42 and 43, or a third party application and device,such as a blood pressure cuff, representative of the patient's bloodpressure, such that controller 37 regulates flow through the SVCresponsive to the patient's blood pressure.

Controller 33 may be programmed to cause the flow limiting element (fromFIGS. 4, 5A, 5B, 6, 8A-10B) to expand when a sensed parameter is outsidea predetermined range and/or above or below a predetermined threshold.For example, controller 33 may cause the flow limiting element to expandwhen right atrium (“RA”) pressure is sensed by optional sensors 42and/or 43 to be within a predetermined range, e.g., 15 to 30 mmHg, 18 to30 mmHg, 20 to 30 mmHg, 20 to 25 mmHg, or above a predeterminedthreshold, e.g., 15 mmHg, 18 mmHg, 20 mmHg, 22 mmHg, 25 mmHg, 30 mmHg.As another example, controller 33 may cause the flow limiting element toexpand when the mean pulmonary artery (“PA”) pressure is sensed byoptional sensors 42 and/or 43 to be within a predetermined range, e.g.,15 to 30 mmHg, 18 to 30 mmHg, 20 to 30 mmHg, 20 to 25 mmHg, or above apredetermined threshold e.g., 15 mmHg, 18 mmHg, 20 mmHg, 22 mmHg, 25mmHg, 30 mmHg. The predetermined range and/or the predeterminedthreshold may be patient specific and controller 33 may be programmedand reprogrammed for individual patients.

Referring now to FIGS. 8-10, alternative forms of intravenous flowlimiting elements suitable for use to occlude the SVC are described. Aswill be apparent to one skilled in the art, while FIGS. 4-6 depict acylindrical flow limiting element, other shapes may be used. Inaddition, while not illustrated with anchoring members in FIGS. 8-10,anchoring members may be included. In each pair of drawings, 8A, 8B, 9A,9B and 10A, 10B, the pair-wise drawings depict that each flow limitingelement has a collapsed contracted state (FIGS. 8A, 9A and 10A), wherethe flow limiting element does not significantly impede blood flow, andan expanded deployed state (FIGS. 8B, 9B and 10B), in which the flowlimiting element partially of fully occludes blood flow through the SVC.

In particular, referring to FIGS. 8A and 8B, catheter 70 includesballoon 71 attached to distal end 72. Balloon 71 is illustrated ashaving a rounded ball shape.

Referring now to FIGS. 9A and 9B, catheter 80 includes flow limitingelement 81 comprising spring-loaded plug 82 formed of a biocompatiblematerial (e.g., beryllium) and having a tapered conical shape.Spring-loaded plug 82 is captured in its collapsed contracted statewithin sheath 83 disposed at distal end 84 of catheter 80. Moreparticularly, a vertex of conically-shaped plug 82 is positionedadjacent the proximal end 85 of sheath 83. During delivery of catheter80, spring-loaded plug 82 is captured within sheath 83 in itslow-profile state to allow blood flow in the SVC. To expandspring-loaded plug 82, force is applied via actuation wire 86 towithdraw plug 82 from sheath 83. As for the previous embodiments, plug82 is biased to return within sheath 83 when the proximal force isremoved from the proximal end of actuation wire 86, so that the flowlimiting element 82 remains in its collapsed contracted state ifdisconnected from controller 33.

Referring to FIGS. 10A and 10B, catheter 90 depicts a furtheralternative embodiment of occlusive device 91, which takes the form ofspring-loaded plug 92. Spring-loaded plug 92 is similar to plug 82 ofFIGS. 9A and 9B, and has a tapered conical shape and is loaded withinsheath 93 disposed at distal end 94 of catheter 90. In response to adistally-directed force applied by drive mechanism 36 to the proximalend of catheter 90, spring-loaded plug 92 is pushed out of distal end ofsheath 94 and expands to occlude the SVC. When the distally-directedforce is removed, spring-loaded plug 92 retracts to its collapsedcontracted state within sheath 94, thereby permitting blood to flowsubstantially unimpeded through the SVC.

Applicants have observed that preliminary animal resting indicates thata system constructed and operated in accordance with the methods of thepresent disclosure provides significant benefits over previously-knownsystems for treating heart failure. Results of such preliminary testingconducted on swine models one week post myocardial infarction aredescribed below.

Referring to FIG. 11, simultaneous LV pressure and volume and Aorticpressure measurements are shown across 40-50 successive heart beats in aswine model of heart failure following either full occlusion of theinferior vena cava (IVC; FIGS. 11 A and B) as suggested in the foregoingpublished Cedeno patent application or full occlusion of the superiorvena cava (SVC; FIGS. 11 C and D). Left ventricular end diastolicpressure corresponds to lower right-hand corner of the pressure-volumeloop and left ventricular systolic pressure corresponds to upperleft-hand corner of the pressure-volume loop in FIGS. 11A and 11C.Within this brief period of time, IVC occlusion rapidly and decreased LVpressure, volume, and aortic pressure to critically low values withpotentially dangerous consequences to the patient (FIGS. 11 A and B).Compared to IVC occlusion, across the same time period, SVC occlusionmarginally decreased LV systolic pressure and aortic pressures, butsignificantly decreased LV diastolic pressure, which is the primarymarker of congestive heart failure (FIGS. 11 C and D). These findingsindicate that SVC occlusion may provide a superior approach to reducingLV filling pressures without detrimental effects to systemic bloodpressure.

Referring to FIG. 12, as noted above, IVC occlusion increased renal veinpressure from 5 mmHg to 15 mmHg within the 30-40 seconds of occlusion(FIG. 12A). After 2 minutes peak renal vein pressure was 23 mmHg. Incontrast, SVC occlusion did not affect renal vein pressure across anytime period studied (FIG. 12B). These findings suggest that IVCocclusion may result in congestion of the renal and hepatic veins, whichcould give rise to exacerbate, rather than ameliorate, complicationsoften associated with congestive heart failure including liver andkidney failure.

Advantageously, the method of the present disclosure of partiallyoccluding the SVC appears to have little or no impact on ejectionfraction during systole, but reduces wall stress in the ventriclesduring diastole. Moreover, occlusion of the SVC is expected to betolerated well by the patient, will not contribute to congestion of therenal or hepatic veins, and will not exacerbate complications oftenassociated with congestive heart failure.

FIGS. 13-14 are graphs showing the changes in pressure as a function ofleft and right ventricular volume, respectively, during occlusion of thesuperior vena cava (SVC) and release in a swine treated for heartfailure in accordance with the principles of the present disclosure. Asshown in the graphs, SVC occlusion led to a significant reduction inleft ventricular (LV) volume (240 to 220 mL) and a reduction in LVdiastolic pressure (25 to 10 mmHg). SVC occlusion also was associatedwith reduction in LV systolic pressure (94 to 90 mmHg). SVC occlusionalso decreased right ventricular (RV) volume (230 to 210 mL), diastolicpressure (12 to 4 mmHg), and RV systolic pressure (27 to 16 mmHg).Advantageously, SVC occlusion in accordance with the systems and methodsdescribed herein reduces biventricular volume and diastolic (filling)pressures without negatively impacting systemic blood pressure (LVsystolic pressure). These findings suggest that SVC occlusion has apotentially important beneficial effect on biventricular interactionsuch that reducing diastolic filling pressures in both ventricles allowsfor increased ventricular compliance, thereby improving ventricularfilling and resulting in increased stroke volume and cardiac output,which is the primary objective when treating a patient with heartfailure.

FIG. 15 includes graphs showing that superior vena cava (SVC) occlusionin accordance with the principles of the present disclosure on a swinesubject improves cardiac function. The graphs each show the results forpartial inferior vena cava (IVC) occlusion (left side of each graph)versus full SVC occlusion (right side of each graph). The graphs showmeasured left ventricle (LV) stroke volume, cardiac output, LVcontractility, LV diastolic pressure, LV systolic pressure, andend-systolic volume.

FIG. 16 is graph showing that SVC occlusion in accordance with theprinciples of the present disclosure on three swine subjects does notharm systolic blood pressure. The graph shows the full caval occlusion(1 minute) LV end systolic pressure (mmHg) for full IVC occlusion (leftside of each study) versus full SVC occlusion (right column of eachstudy). Less reduction in LV-end-systolic pressure with SVC occlusioncompared to IVC occlusion.

FIG. 17 is graph showing that SVC occlusion in accordance with theprinciples of the present disclosure on three swine subjects does notharm LV diastolic filling. The graph shows the full caval occlusion (1minute) LV end diastolic pressure (mmHg) for full IVC occlusion (leftside of each study) versus full SVC occlusion (right side of eachstudy). Less reduction in LV-end-diastolic pressure with SVC occlusioncompared to IVC occlusion.

FIG. 18 is graph showing that SVC occlusion in accordance with theprinciples of the present disclosure on three swine subjects improves LVstroke volume. The graph shows the full caval occlusion (1 minute) LVstroke volume (mL/beat) for full IVC occlusion (left side of each study)versus full SVC occlusion (right side of each study). Increased LVstroke volume with SVC occlusion compared to reduced LV stroke volumeIVC occlusion.

FIG. 19 is graph showing that SVC occlusion in accordance with theprinciples of the present disclosure on three swine subjects improves LVcontractility. The graph shows the full caval occlusion (1 minute) LVcontractility (mmHg/sec) for full IVC occlusion (left side of eachstudy) versus full SVC occlusion (right side of each study). IncreasedLV contractility with SVC occlusion compared to reduced LV contractilitywith IVC occlusion.

FIG. 20 is four graphs depicting LV total volume and LV pressure for IVCocclusion (upper left), RV total volume and RV pressure for IVCocclusion (upper right), LV total volume and LV pressure for SVCocclusion (lower left), and RV total volume and RV pressure for SVCocclusion (lower right). FIG. 20 illustrates that SVC occlusion providesa significant reduction in LV and RV diastolic pressures without a majorreduction in LV systolic pressure as compared to IVC occlusion.

FIG. 21 is two graphs depicting measured pulmonary artery pressure andrenal vein pressure in a swine subject for IVC occlusion (left graph)and SVC occlusion (right graph). Line 100 shows the measured pulmonaryartery pressure while line 102 shows the measured renal vein pressurefor IVC occlusion. Line 104 shows the measured pulmonary artery pressurewhile line 106 shows the measured renal vein pressure for SVC occlusion.The max renal vein pressure is measured to be 22 mmHg for IVC occlusionwhereas the max renal vein pressure is measured to be 7 mmHg for SVCocclusion. FIG. 21 demonstrates that SVC occlusion reduces pulmonaryartery pressures without increasing renal vein pressure as compared toIVC occlusion.

FIG. 22 is a graph depicting measured left subclavian vein pressure andrenal vein pressure in a swine subjected to SVC occlusion in accordancewith the principles of the present disclosure. Line 108 shows themeasured left subclavian vein pressure while line 110 shows the measuredrenal vein pressure for SVC occlusion. The measured change in leftsubclavian vein pressure is 5 to 12 mmHg during SVC occlusion. FIG. 22demonstrates that proximal left subclavian vein pressure increasesnominally during SVC occlusion.

Applicants expect that use of the system and methods of the presentdisclosure for a period of several hours, days, weeks, or months after apatient is admitted to a hospital showing the symptoms of heart failurewill result in arresting or reversing further myocardial remodeling anddegeneration. In particular, because a system constructed in accordancewith the principles of the present disclosure may be designed to beimplanted or worn by the patient continuously and in an ambulatorysetting, rather than being tethered to a bed, e.g., in an acute-caresetting, the patient will see continuous improvement in myocardialfunction throughout the course of treatment. In addition, by enablingthe system to interface with commercially available heart rate monitorsand smartphones and/or tablets, the system provides both reduced costand reduced complexity.

Applicants expect that the systems and methods of the present disclosuremay be used alone, as described in the examples, above, or incombination with other devices configured to assist cardiac function,such as an intra-aortic balloon pump (“IABP”), a percutaneous leftventricular assistance device (LVAD) or with a surgical LVAD, therebyallowing for synchronous or asynchronous, (venous and arterial)unloading of cardiac preload and afterload, respectively. By reducingcardiac preload, left ventricular wall tension is reduced, therebyallowing for improved functionality of a left ventricular assist device.

It is to be understood that the foregoing description is intended toillustrate and not to limit the scope of the invention, which is definedby the scope of the appended claims. Other embodiments are within thescope of the following claims.

What is claimed is:
 1. A system for treating heart failure in a patient,the apparatus comprising: a catheter having a proximal end and a distalregion, the catheter configured for placement though a subclavian orjugular vein of a patient so that the distal region is disposed in asuperior vena cava of the patient; a flow limiting element disposed onthe distal region of the catheter, the flow limiting element configuredto be selectively actuated to at least partially occlude the superiorvena cava; and a controller configured to operatively coupled to thecatheter to intermittently actuate the flow limiting element to at leastpartially occlude the superior vena cava over multiple cardiac cycles,the controller including a processor programmed to: apply a stored valuecorresponding to a predetermined flow limiting interval during which theflow limiting element is to be actuated; receive an input correspondingto a physiologic parameter of the patient indicative of fluctuations inthe patient's hemodynamic state resulting from the patient's ambulatoryactivity; generate an output corresponding to an adjustment of thepredetermined flow limiting interval; and apply the output to revise thepredetermined flow limiting interval.
 2. The system of claim 1, whereinthe proximal end of the catheter is adapted to extend outside thepatient and the controller has a size and weight selected to enable thecontroller to be worn by the patient during ambulatory activity.
 3. Thesystem of claim 1, wherein the controller further comprises a drivemechanism configured to be coupled to the flow limiting element of thecatheter.
 4. The system to claim 1, further comprising a data transfercircuit configured to receive data from a sensor and to provide theinput to the processor of the controller.
 5. The system of claim 1,wherein catheter comprises one or more sensors.
 6. The system of claim5, wherein the one or more sensors comprise at least a blood pressuresensor and electrodes for detecting a heart rate of the patient.
 7. Thesystem of claim 4, wherein the data transfer circuit is configured towirelessly receive data from a heart rate monitor.
 8. The system ofclaim 4, wherein the data transfer circuit is configured tobi-directionally communicate physiologic data to a computing device ofthe patient for display to the patient.
 9. The system of claim 8,wherein the controller is programmed to send an alert condition to aclinician monitoring the patient via a cellular communicationscapability of the computing device.
 10. The system of claim 3, whereinthe flow limiting element is coupled to the drive mechanism via anactuation wire.
 11. The system of claim 3, wherein the flow limitingelement transitions from a collapsed contracted state to an expandeddeployed state when actuated by the drive mechanism.
 12. The system ofclaim 3, wherein the flow limiting element transitions from a collapsedcontracted state to an expanded deployed state when actuated by thedrive mechanism, and the flow limiting element is configured totransition to the collapsed contracted state if operatively disconnectedfrom the controller.